University of South Florida Morsani College of Medicine Tampa, FL, United States
Chanlir Segarra, MD, Pushpak Taunk, MD University of South Florida Morsani College of Medicine, Tampa, FL
Introduction: Roux-en-Y gastric bypass (RYGB), a common surgery performed for weight loss in the United States, poses a significant challenge when trying to assess and treat pancreaticobiliary diseases using EUS and ERCP. Here, we present a case that demonstrates the effectiveness of performing an endoscopic ultrasound directed trans gastric ERCP (EDGE) procedure in a RYGB patient presenting with obstructive jaundice.
Case Description/Methods: A 56-year-old female with a past medical history of RYGB, GERD, HTN, and HLD presented with yellow skin, abdominal pain, and weight loss. Physical exam revealed scleral icterus and jaundice but was otherwise unremarkable. Labs showed a bilirubin 4.9, ALK 2288, AST 177, ALT 243. Abdominal ultrasound revealed moderate sludge in the gallbladder with a dilated CBD of 13 mm.
MRCP confirmed CBD dilation and noted stenosis in the distal CBD. The pancreatic head was mildly prominent without evidence of a mass. Initial EUS was limited due to patient’s RYGB anatomy, and the pancreatic head was not visualized. There was, however, a 23mm by 28mm oval hypoechoic, heterogeneous mass noted in the pancreatic neck. Fine needle biopsies were negative. Given inability to obtain a diagnosis, EUS was then used to place a 20mm x 10mm AXIOS stent between the jejunal limb and gastric remnant to facilitate future access to the remnant stomach with an EDGE procedure.
After the jejuno-gastric tract matured over two weeks, a subsequent ERCP was performed through the AXIOS stent. ERCP showed a distal CBD stricture and SpyGlass cholangioscopy showed increased vascularity in the biliary mucosa. Biopsies and brushings were negative, IgG4 was elevated at 427 and CA 19-9 was normal. Given lack of a defined mass, negative biopsies, and elevated IgG4, the patient was presumed to have autoimmune cholangiopancreatitis and was placed on a prednisone taper. 2 months later, the EDGE procedure was repeated with improvement in the CBD stricture. Repeat SpyGlass cholangioscopy revealed normal biliary mucosa, and IgG4 decreased to 115. Given steroid response, autoimmune cholangiopancreatitis was confirmed.
Discussion: Due to altered anatomy, performing a standard or enteroscopy assisted ERCP in patients with a prior RYGB is often challenging and unsuccessful. This case report highlights the benefit of the EDGE procedure in diagnosing a RYGB patient with autoimmune pancreatitis, thus preventing more invasive surgical diagnostic procedures for obstructive jaundice.
Chanlir Segarra indicated no relevant financial relationships.
Pushpak Taunk indicated no relevant financial relationships.
Chanlir Segarra, MD, Pushpak Taunk, MD. P1749 - Novel Use of the EDGE Procedure in Diagnosing a Case of Type 1 Autoimmune Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.